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Jie (rhythm/pulse phase). Whenever a disease presents with deficiency or excess, corresponding manifestations will appear. The ability to eat but inability to defecate indicates intake without discharge, representing an excess of Yang. If the condition worsens on the 17th day, it is because Yang governs advancement, aligning with the odd numbers associated with Yang. Inability to eat while hard stools are still passed indicates discharge without intake, representing a deficiency of Yang. If the condition worsens on the 14th day, it is because Yin governs retreat, aligning with the even numbers associated with Yin. Pulse methodology states: "To calculate the remaining lifespan and the time of death, one must consider the mutual overcoming by monthly solar terms." The *Neijing* (Yellow Emperor's Inner Canon) states: "Those who can eat will exceed the expected period; those who cannot eat will not reach the expected period." This is what is meant.

This clause originally discusses Yin Jie (Yin Knotting/Constipation). Yang Jie (Yang Knotting/Constipation) is essentially Stomach Excess (Wei Shi), serving as a companion to Yin Jie. Yin Jie has no exterior syndrome and should be attributed to Shaoyin disease. One cannot regard heavy body and inability to eat as symptoms that Yangming disease should have, nor sinking and slow pulse as pulses that Yangming disease should show. Hard stool belongs to Stomach Excess, so warming and tonifying agents must not be used. Furthermore, Yin Jie differs from Gu Jia (Solid Masses) and Gu Dan (Grice Jaundice). Those with loose stools but difficulty in defecation have excess within deficiency; here, hard stools with the urge to defecate indicate deficiency within excess. It is urgent to use Ginseng and Aconite to restore Yang and rescue from collapse; do not delay until the deadline passes without being able to save the patient.

The above discusses Yin and Yang Jie syndromes.

In Yangming disease, if the pulse is slow, sweating is profuse, and there is slight aversion to cold, the exterior is unresolved. Sweating may be induced, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate.

In Yangming disease, if the pulse is floating, there is no sweating and wheezing, inducing sweating will lead to recovery, and Mahuang Tang (Ephedra Decoction) is appropriate.

These are the exterior syndromes and exterior pulses of Yangming disease. These two conditions are identical to Taiyang disease, but are attributed to Yangming because there is no stiffness and pain of the head and neck. One must understand that these two formulas are specifically designed for exterior pathogens, not for Taiyang disease per se. When Mahuang Tang syndrome is seen, use Mahuang Tang; when Guizhi Tang syndrome is seen, use Guizhi Tang; there is no need to ask whether it is Taiyang or Yangming. Once aversion to cold ceases, these two formulas become strictly contraindicated.

In Yangming disease, if the pulse is floating and tight, tidal fever (Chao Re) occurring at specific times is inevitable; if the pulse is only floating, night sweats (Dao Han) are inevitable.

The pulse and symptoms in the previous clause are the same as Taiyang disease, whereas those in this clause differ from Taiyang disease. These are the half-exterior, half-interior pulse and symptoms of Yangming disease. If Mahuang Tang or Guizhi Tang are swallowed, excessive Yang will lead to death. Therefore, skilled diagnosticians must differentiate pulse based on symptoms, not discuss symptoms based on pulse. Full annotations are found earlier in this chapter.

If the pulse is floating and slow, with facial heat, redness, trembling, and fearfulness, sweating and resolution should occur after six or seven days. Slow pulse indicates lack of Yang, inability to produce sweat, and the body will likely itch.

This is the deficiency syndrome and deficiency pulse of Yangming disease. Pathogens strike the face, and Yangming Yang rises to support it. Thus, the face is hot and red. Yang gathers upward, leaving the exterior defense deficient; cold pathogens cut into the skin, causing trembling and fearfulness. With this pulse and symptom, it is impossible for aversion to cold to cease spontaneously within two days. It is necessary to wait for the recovery of Stomach Yang after six or seven days, allowing for profuse sweating and resolution. The reason is that sweat is generated by Yang Qi, and slow pulse is a Yin pulse; without Yang, sweat cannot be produced. This can also be verified by body itching. This situation requires assisting Yang to induce sweating.

In Yangming disease, according to the method, there should be profuse sweating. If there is instead no sweating, and the body feels like insects crawling in the skin, this is due to long-standing deficiency.

Yangming has abundant Qi and Blood, hence profuse sweating; if the person has been deficient for a long time, there is instead no sweating. In this case, one should replenish fluids and harmonize Ying and Wei (Nutritive and Defensive levels), allowing Yin and Yang to naturally harmonize and sweat to occur.

In Yangming disease, if there is no sweating but urination is free, and after two or three days vomiting and coughing occur with cold limbs, severe headache will ensue. If there is no coughing or vomiting, and limbs are not cold, the head will not hurt.

Free urination indicates no stasis-heat in the interior. After two or three days, without the exterior signs of fever, sweating, and aversion to heat, internal signs of vomiting and coughing appear immediately, suggesting heat originating from Yin. Coupled with cold limbs, it seems the disease is in the Three Yin meridians. Severe headache seems like a Taiyang meridian syndrome. However, since the headache is caused by coughing, vomiting, and limb reversal, the headache does not belong to Taiyang. Since coughing, vomiting, and limb reversal inevitably cause headache, the limb reversal does not belong to Three Yin. It is definitively a deficiency syndrome of the half-exterior, half-interior aspect of Yangming disease. This is because Stomach Yang cannot distribute to the four limbs, causing cold limbs, and cannot rise to the forehead, causing headache. The pathogen struck the chest area, knotting in the chest, leading to vomiting and coughing which damaged Yang. Genti San (Thistle Powder) should be used to induce vomiting; once vomiting and coughing stop, the cold limbs and headache will naturally resolve. Read "Liang Zhe" (Both) as "Shi Zi" (At this time) for greater clarity.

In Yangming disease, if there is only dizziness, no aversion to cold, thus the ability to eat and coughing, the person will definitely have a sore throat. If there is no coughing, the throat will not hurt.

No aversion to cold, no headache but only dizziness indicates the Yangming exterior has resolved. Ability to eat without vomiting or cold limbs, but only coughing, indicates coughing is the root of the disease. Sore throat is caused by coughing; dizziness is also caused by coughing. This is pathogen knotting in the chest while the Stomach is not yet solid. Treatment should follow the modification methods of Xiaochaihu Tang (Minor Bupleurum Decoction).

In Yangming disease, if there is dry mouth, only wanting to rinse water in the mouth without swallowing, epistaxis (nosebleed) will certainly occur.

If the pulse is floating, there is fever, dry mouth and nose, and the person can eat, epistaxis will occur.

Pathogens strike the face, and the disease is in the meridians. Fluids and blood are different names but of the same category. When fluids are exhausted, blood vessels are consequently injured. Thus, Yangming governs diseases generated by fluids and diseases generated by blood. Yangming meridian begins at the nose and connects to the teeth and mouth. In Yangming disease, fluids are insufficient, causing dry mouth and nose. Excessive Yang injures the Yang collaterals, causing blood to overflow upwards resulting in epistaxis. Dryness of fluids in the mouth and nose causes the desire to rinse water but not swallow, indicating heat is in the mouth and nose, not having entered the interior. Ability to eat indicates strong Stomach Qi. Given the pulse floating and fever, along with the pathology of dry mouth and nose, if the disease is in Yangming, further examining the condition of eating and not wanting to swallow water reveals that heat is in the Blood level, not the Qi level. This is known through inquiry.

Note: Both Taiyang and Yangming are meridians with abundant blood, so both have blood syndromes. Taiyang pulse should ascend; when Ying Qi rebels and does not follow its path, it descends along the vertex to the inner canthus, borrowing the way through Yangming, exiting from the nostrils, hence eye dimness and headache occur first. Yangming pulse should descend; when Ying Qi rebels and does not descend, it ascends along the teeth, circles the lips, and goes up the lateral nose to enter the nostrils, hence dry mouth and nose occur first. They have different sources but the same flow because the Yangming meridian begins at the intersection of the nose, laterally accepting the Taiyang meridian.

These two clauses only discuss pathology, not pulse methods or treatment, so Tao Ren Cheng Qi Tang (Peach Kernel Modifying the Stomach Decoction) or Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) types are appropriate.

The above discusses Yangming exterior pulse and symptoms.

In Shanghan (Cold Damage) after four or five days, if the pulse is sinking with wheezing and chest fullness, sinking indicates the disease is in the interior. Inducing sweating in error causes fluids to escape, making stool difficult. Exterior deficiency and interior excess, over time, lead to delirious speech (Chan Yu).

Wheezing and chest fullness are Mahuang syndrome. However, the pulse must be floating for the disease to be in the exterior, allowing for sweating. Now, the sinking pulse indicates the disease is in the interior, so wheezing and fullness belong to the interior. Attacking the exterior in error causes exterior deficiency, leading to massive fluid loss. Wheezing and fullness become fullness and excess, transferring to Yangming, which is the origin of delirious speech. Administer a small amount of Tiao Wei Cheng Qi Tang (Modifying the Stomach Decoction). Sweating indicates exterior deficiency, but for delirious speech, the emphasis is solely on interior excess.

Profuse sweating, or repeated sweating, leads to loss of Yang. Delirious speech with a short pulse indicates death; delirious speech with a self-harmonious pulse indicates survival.

The previous clause discusses the cause of delirious speech; this clause discusses the pulse of delirious speech. Loss of Yang is a synonymous expression for fluid escape. The fluid of the Heart is Yang sweat; the pulse is the mansion of blood. The Heart governs blood vessels. Profuse sweating depletes fluids and weakens Ying Blood. Thus, a short pulse indicates Ying and Wei do not circulate, and Zang-Fu are blocked, leading to death. For delirious speech with a self-harmonious pulse, although fluids are wasted, they are not severely depleted. As long as Stomach excess exists, Ying and Wei are regulated, and the pulse contains Stomach Qi, so death does not occur. The following lists cases where delirious speech is not due to Stomach excess.

Delirious speech with fixed staring, wheezing, and chest fullness indicates death; diarrhea also indicates death.

The previous clause mentions the fatal pulse; this clause mentions fatal symptoms. Generally, delirious speech is due to Stomach excess and is not inherently fatal. If delirious speech presents with deficiency pulse and deficiency symptoms, it is fatal, not Stomach excess. The essence and Qi of all Zang-Fu organs ascend to the eyes. If the eyes do not move and the person does not recognize others, the Qi of the Zang-Fu organs has exhausted. Wheezing and fullness appearing before sweating indicate interior excess; appearing during delirious speech indicates Lung Qi has failed. Difficulty in breathing causes continuous wheezing. Spleen deficiency prevents the transport of fluids for the Stomach, causing fullness without movement. If diarrhea continues unceasingly, the granary is not stored, and the gates are not guarded. This is worlds apart from difficulty in defecation with delirious speech.

Excess leads to delirious speech (Chan Yu); deficiency leads to Zheng Sheng (repetitive speech). Zheng Sheng refers to repetitive speech.

Although both are called delirious speech, there is a distinction between excess and deficiency. When pathogens are vigorous, it is excess; speech is absurd but differs from mania, possessing a solemn demeanor, named Chan Yu. When healthy Qi is depleted, it is deficiency; the person sees ghosts and spirits, speaking with gravity, showing a state of seeking life and help, named Zheng Sheng. This distinguishes from Chan Yu to clarify that Chan Yu can occur without Stomach excess. Explaining "Zhong Yu" (heavy/repetitive words) shows the meaning of gravity, not just the sound. If the character originated from the throat, implying repetitive and lingering speech, who would not know it is deficiency? Why did Zhang Zhongjing distinguish it?

In Yangming disease, if there is bleeding from the lower orifices and delirious speech, this is Heat entering the Blood Chamber (Xue Shi). If only the head sweats, puncture Qimen (Liv 14), draining the excess according to its reality, and profuse sweating will lead to recovery.

The Blood Chamber is the Liver. The Liver stores blood, hence called Blood Chamber. Women rely on blood, so bleeding disorders are most common. Men, unless injured, do not have bleeding disorders. Only Yangming governs diseases generated by blood; its meridian has abundant blood and Qi, running along the front of the body, adjacent to Chong and Ren meridians. When Yangming heat is excessive, invading the Blood Chamber, the Blood Chamber fails to store, and blood overflows from the anterior orifice, so both men and women can have this syndrome. Blood disorder means Hun (Ethereal Soul) has no return, and Shen (Spirit) has no master, so delirious speech occurs. Understand that this is not Stomach excess, but Liver excess due to heat entering the Blood Chamber. Liver heat causes Heart heat; heat damages Heart Qi, which neither governs blood nor produces sweat. Only the head sweats, not the whole body; this cannot be cured by sweating, vomiting, or purging methods. One must puncture the Front-Mu point of the Liver, drawing blood back to the meridians, pushing out the old and generating the new, allowing heat to vent. Then the Liver is stored, Heart is mastered, Hun has a return, and Shen has a basis. Naturally, the whole body sweats, blood does not flow recklessly, and delirious speech stops. Note: Accumulated blood causing pus and blood in stool is always heat entering the Blood Chamber, entering the intestines and stomach, and exiting from the anus, called bloody pus stool. Women's menstrual blood comes from the uterus, differing from the urinary tract. In men, semen, blood, and urine have different internal pathways but share an external opening; semen pathway is Kidney, blood pathway is Liver, water pathway is Bladder. Their sources are distinct but all exit from the anterior orifice.

Qimen is the Front-Mu point of the Liver and the meeting point of Foot Taiyin, Foot Jueyin, and Yinwei Mai. Taiyin and Yangming are exterior-interior pairs; Jueyin and Shaoyang are exterior-interior pairs. Treating Yin for Yang diseases, therefore, blood diseases of Yangming and Shaoyang can be treated by puncturing this point.

In a woman with Fengzhong (Wind Strike), fever and aversion to cold, menstruation happens to arrive. After seven or eight days, heat subsides, pulse becomes slow, body cools, but there is fullness under the chest and hypochondrium, resembling Jie Xiong (Chest Binding), and delirious speech. This is heat entering the Blood Chamber. Puncture Qimen, draining the excess according to its reality.

The twelve meridians of the human body correspond to the twelve waters of the earth, hence blood is called Jing Shui (Menstrual Water). Women belong to Yin and have abundant blood. The pulse is the mansion of blood. Pulses correspond to the moon, so women's menstrual water overflows monthly, coming down on time, hence called Yue Shi (Monthly Affairs). Here, a woman contracts wind pathogen during menstruation, presenting with fever and aversion to cold. At this time, menstruation is not yet considered; since the disease comes from outside, resolving the exterior first is known. By the seventh or eighth day, heat subsides, body cools, and pulse slows, indicating recovery. Instead, chest and hypochondriac distress appears, not Jie Xiong, and delirious speech occurs, not Stomach excess. Why? Because of the slow pulse. Slow pulse indicates disease in the Zang. It must be that when menstruation arrived, external wind-cold combined with internal heat attacking the Liver, and residual blood from incomplete menstruation must knot. Puncturing the Mu point drains the knotted heat; fullness dissipates and delirious speech stops. This is using obstruction to treat obstruction (Tong Yin Sai Yong).

In a woman with Shanghan (Cold Damage) and fever, menstruation happens to arrive. During the day she is lucid; at night she deliriously speaks, seeing things. This is heat entering the Blood Chamber. Do not violate Stomach Qi, nor the Upper and Lower Jiao; it will heal itself.

The previous text mentioned Fengzhong; this mentions Shanghan, indicating that both Fengzhong and Shanghan in women can present with heat entering the Blood Chamber. However, these three clauses all originate from delirious speech, not emphasizing heat entering the Blood Chamber, nor Shanghan/Fengzhong. Understand that delirious speech often does not stem from Stomach excess; one must not assume Stomach excess and violate Stomach Qi. Fever without aversion to cold is Yangming disease. Delirium at Shen and You hours (3-7 PM) suggests Stomach excess. But if menstruation is arriving, it is certainly heat entering the Blood Chamber. This menstruation has not stopped, differing from the blood knotting in the previous clause. It is Liver deficiency causing Hun insecurity and hallucinations; there is no excess to drain. One must not blindly purge to damage Stomach Qi. Nor should one puncture to induce sweating, damaging Upper Jiao Yang; nor puncture to bleed, damaging Lower Jiao Yin. Wait for menstruation to end, then delirious speech will cease and fever will recede. Treat by not treating.

Heat entering the Blood Chamber, with chills and fever like malaria but without delirious speech, belongs to Chaihu syndrome.

The above discusses Yangming delirious speech pulse and symptoms.